Registered Nurse Senior

Hiring a Registered Nurse for a great hospital FULLY REMOTE MUST HAVE medical/medicare experience along with active CA RN license to apply!Schedule: Monday – Friday, 8am to 5pmDay to Day Responsibilities:

The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Medi-Cal Appeals and Grievances RN will report to the Appeals and Grievances Manager.

In this role you will perform accurate and timely clinical review of Member-initiated appeals.

The RNs perform first level appeal reviews for members utilizing the National Coverage Determination (NCO) guidelines, Local Coverage Determination (LCD Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOO.

The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance.

In this role you will also perform Clinical oversight of all Medi-Cal grievances.

In this process, the candidate will work with the medical directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases, and/or Quality of Care (QOC) to ensure member’s clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited.

Requirements:

Knowledge of Medi-Cal benefits and reviews required

Requires 2 years of health insurance or related experience required

Demonstrate the ability to act independently using sound clinical judgement required

Works well in a fast paced team environment preferred

Excellent communication skills preferred

Office, Excel, Email skills required

CA RN License Required

About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

Hiring diverse talent

Maintaining an inclusive environment through persistent self-reflection

Building a culture of care, engagement, and recognition with clear outcomes

Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.